A doctor urges fellow child health practitioners to speak up for the benefits of social protection policy, and to measure, evaluate and bear witness to the impact of NHS 'reform' on child health.
“Britain is failing its young children on a grand scale”, says Professor Sir Michael Marmot, leading expert on social inequalities and advisor to the UK government and the World Health Organization. This is no exaggeration. Health and wellbeing among children and young people is poor: more children rate their health as fair or poor than average for comparable countries child wellbeing is bottom of the league of wealthy countries; infant and child mortality rates for the UK are among the highest in the European Union); and healthcare amenable mortality is higher than comparable European countries too. Indeed it would be fair to say that health and wellbeing among Britain’s children and young people are precarious.
What impact does the economic crisis have on child health?
It is too early to assess much of the direct health impact, but we do know a lot about what is likely to happen. First, we know that child mortality is related to a country’s wealth as measured by gross domestic product (GDP). We also know that the amount of spending on social protection for families — like helping with the costs of raising children, and subsidised housing — is related to child mortality. In other words, the economy matters for health: more children die when countries are in economic hardship, but there are things that can be done to soften the blows. Government’s choices on social policy affect the lives and deaths of children.
How did we get into this mess?
The financial crisis probably had its origins with the housing bubble and unsafe loans, but the groundwork was laid by deregulation of the banks. A toxic mix of easy money, greed and corruption ultimately led to the collapse of banks, and a stock market crash. When things got bad for the banks, they were bailed out — with tax-payers’ money. But when things got bad for people, they lost their homes. In 2010 the new government faced a big problem, but also an opportunity. They claimed there was no money left, and that austerity was the solution. We were all to be in it together, tightening our belts for the future security of the country. We have a big problem with the debt, and the deficit, we were told.
Look close and you’ll see that our deficit is indeed a problem, but the national debt is a different matter. The UK’s debt is lower than most countries, and it doesn’t have to be paid back or refinanced for a very long time indeed. What is worrying about our debt is that it is mostly carried by households and by banks. And we’ve seen the difference between what happens when banks need help, and when households need help.
It’s vital to be clear about what the exact nature of the economic problems are, because, just as in medicine, the diagnosis determines the treatment. It's true that other things come into it. In medicine personal circumstances and co-morbidity affect decisions about treatment. In economic policy-making, politics and ideology are crucial elements. Where does that leave the evidence?
In search of a solution.
There are two poles of economic theory, and nothing like a randomised controlled trial or meta-analysis to help determine which is better. This is territory ripe for mixing evidence with ideology. You can look at what happened in certain circumstances, when specific policies were enacted. John Maynard Keynes wrote “The Means to Prosperity” in 1933 during the Great Depression. There are many economic parallels between then and now: high unemployment, low economic growth, high deficit. Keynes was a strong believer in activist government. And believed that government spending on things like national infrastructure was a remedy for the depression. It worked.
The other economic pole is occupied by the monetarists, most notably Milton Friedman. Monetarists believe that the way to stimulate growth is to increase personal spending, and the way to do that is to cut taxes to stimulate business. Reduced government spending is an inevitable consequence of tax cuts, but there’s usually also an ideological slant towards reducing the size of the state. This approach comes at a high human cost to the most vulnerable people.
What is the economic crisis doing to health?
Unemployment is related to an increase in violent deaths, from suicide and homicide. There is high youth unemployment, risking a generation of people disconnected from the labour market. Children are born into workless households. People will lose faith in important public institutions, in government. Human welfare is suffering.
What can health do for the economy?
Quite a lot, actually. Healthy people go to school and to work. They pay their taxes, and contribute to GDP. Investing in health pays dividends. According to the WHO commission on macroeconomics and health, a 10 per cent increase in life-expectancy increases economic growth by 0.3 to 0.4 per cent of GDP per year.
What is the Government doing to protect health?
The Health and Social Care Bill came in as the first big health policy of the new government. This enormous Bill is estimated to cost £2m billion to implement. At the same time, a cost-saving of £20 billion is expected. Social policies are changing too. Child Trust funds, child benefit, tax credits, Sure Start, Education Maintenance Allowances, Disability Living Allowances. All of these are social protection policies, and all are under attack. Meanwhile, discussion among some in government has turned towards redefining poverty as “. . . not about income alone”. Whether this has any relation to the Child Poverty Act target of ensuring the relative child poverty rate being no more than 10 per cent by 2020, and the absolute child poverty rate being less than 5 per cent, is unclear. Current poverty definitions are, however, tied to income. Draw your own conclusions.
What can children’s health professionals do?
We know that part of our role is to act as advocates for children. But what does this mean? It helps to be specific. We need to draw attention, loudly, to the benefits of social protection policy. Expenditure on families, subsidised housing, active labour market programmes, compensation for unemployment, spending on health – all these things save lives.
More generally, we need to document what’s happening to children and families. We need to bear witness. The NHS is a great symbol and, for now, a reality, of social equity. The passage of the Health and Social Care Act will have tremendous consequences on the health and wellbeing of children and young people. We need to measure what’s going on. Evaluating such a large-scale policy is challenging, to say the least. Health systems performance research is a new field, and too few people work in this area, or on health policy analysis for child health.
But there are difficulties too that relate directly to the Act, it will become more difficult to monitor the population’s health effectively and plan health services accurately, when the new primary care commissioning groups are fully up and running.
In a change from the past 65 years of the NHS, there will no longer be a clear way to make sense of information about people in a specific area, matching data about health needs and what services there are currently and what might be needed in the future. This is a step towards insurance-based healthcare – a marketisation process.
It is not clear what the reporting duties of new private health care providers will be. It will be difficult to disentangle the effects of the Act from the impacts of the financial crisis. And the Act is already being implemented, which makes it more complicated still. However none of these difficulties should discourage us from getting started. Indeed there is no time to lose.
What could parents do?
Politicians may listen more to parents than professionals. Be active advocates. Arm yourselves with the evidence, and then write about it, talk about it, lobby about it, and most definitely vote for it.
This piece is drawn from a speech to the British Association of Community Child Health Annual Scientific Meeting in Birmingham on 9 October 2012.
Mortality, health, and wellbeing data:
Health Behaviour of School-age Children. A WHO collaborative cross-national study of children aged 11-15
UNICEF Innocenti research centre
World Health Organization, Health for All database
Wolfe I, Cass H, Thompson M, et al. Improving child health services in the UK: insights from Europe. BMJ 2011; 342: 90-04.
Economics and health references
IMF: International Monetary Fund, Fiscal Monitor Report 2010
Stuckler D, Basu S, Suhrcke M, et al. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315-23
WHO COMMISSION ON MACROECONOMICS AND HEALTH